• There are many fertility options for people who are transmasculine and/or non-binary

• Most of the fertility facilities and resources are gender-specific, binary, and often aimed at heterosexual individuals which can bring up additional challenges.

• It may be helpful to get support from other transmasculine and non-binary individuals pursuing fertility preservation and/or pregnancy.

Contents

Hormones and Fertility

Carrying a pregnancy

Intercourse / ICI / IUI

Preserving and using gametes (eggs) and embryos

IVF Process

Cost Considerations

Fertility Clinic FAQ

Fertility Clinics – Northern California and Resources

Information is provided for general education purposes and is not intended to take the place of a discussion with your physician. If you have questions about any aspect of your health, you are advised to speak with your physician.

Transmasculine / Non-Binary Fertility Options

Hormones and Fertility

Multi-Specialty Transitions Department – NORTHERN CALIFORNIA

Testosterone

• It may be possible to get pregnant while using testosterone even if menses (periods) have stopped.

• Barriers like condoms or other birth control methods are recommended if pregnancy is not a goal.

• When planning a pregnancy, egg retrieval and/or IVF, testosterone will need to be discontinued.

• Some people experience discomfort or dysphoria when testosterone is temporarily discontinued.

Fertility Hormones

• Egg retrieval and IVF require a series of hormone shots (estrogen, progesterone, HCG, and Lupron) that may have emotional and physical side effects resulting in increased discomfort or dysphoria for some people as well.

Carrying a Pregnancy

Multi-Specialty Transitions Department – NORTHERN CALIFORNIA

• It may still be possible to become pregnant and/or produce viable eggs even with long term testosterone use. Research suggests that long term testosterone use does not reduce the number of eggs in the ovaries or affect the ability of eggs to mature.

• It is recommended that a person considering pregnancy consult with a fertility physician and coordinate care with their hormone prescribing doctor.

• Age and other medical factors may affect the possibility of pregnancy.

• If a person has a uterus and ovaries, it typically takes 2-3 months to resume egg releasing cycles (menstruation) after discontinuing testosterone. It is optimal to have at least 2 egg releasing cycles before attempting pregnancy. Even if menstruation hasn’t been supressed with testosterone, it is still recommended to discontinue testosterone 2-3 months before attempting pregnancy.

• If an individual is unable to produce fertile eggs, they can carry an embryo implanted in their uterus through joining gametes (sperm or egg) from a partner and/or donated gametes (sperm or egg).

Fertility Options: Intercourse / ICI / IUI

Multi-Specialty Transitions Department – NORTHERN CALIFORNIA

Intercourse • Fertility option involving the release of sperm inside vaginal canal to enter

cervix. Egg is fertilized with sperm inside the body and embryo implants in the uterus.

• Testosterone should be discontinued prior to attempting pregnancy. • Sperm count can be tested in advance of attempting pregnancy (but

not required). • Other fertility tests possible for carrying partner, depending on age and

number of prior attempts.

ICI – Intracervical Insemination • Fertility option involving the placement of sperm on surface of cervix/ canal • No sperm washing required, can be done at home without assistance

IUI – Intrauterine Insemination • Fertility option involving the use of a catheter to place sperm inside the uterus • Goal is to increase chance of sperm reaching egg • Sperm washing required; can be done at Kaiser or at home with a midwife

Considerations: ▪ These methods described above are less invasive and less expensive than IVF ▪ ICI / IUI:

▪ Lower success rate than IVF ▪ Most effective when using fresh sperm; many people become

pregnant using frozen sperm ▪ Not recommended for people who have prior history of disease of

fallopian tubes, history of pelvic infection or severe endometriosis

People with ovaries have two options for

preserving fertility.

1. They can have eggs extracted and frozen.

2. They can have eggs extracted, fertilized with donated or partner’s sperm, and then have the embryos frozen.

Fertility Options: Preserving and Using Gametes (Eggs) and Embryos

Using Frozen Eggs or Embryos for Pregnancy:

• The procedures are no longer considered experimental, but it is expensive to cryopreserve eggs and/or embryos.

• There is no evidence of increased risk to the parent or child born from this procedure.

• Rates of live births are typically higher when embryos are used instead of eggs. The eggs that are collected for egg banking are more delicate than embryos therefore, there is a greater chance that ice crystals can form during the freezing process that can damage the eggs.

• The younger and healthier an individual’s eggs are, the more likely it is that they will be able to conceive later with this technology.

• With egg freezing, the best outcomes are for individuals who are younger than 35 when their eggs are frozen. Some fertility clinics may offer egg freezing up to age 40, while others may establish an earlier cutoff date. Genetic testing of embryos may be recommended for people using eggs who are over 35. Genetic testing has an additional associated cost.

• Elective egg freezing may assist people who want to preserve their fertility and delay having a child.

Options for Implantation and Pregnancy:

• If an individual has a uterus and ovaries, the fertilized egg or embryo can be implanted into the individual who produced the eggs.

• Fertilized eggs or thawed embryos may also be implanted back into a partner’s uterus or into a surrogate.

• If a person has had a hysterectomy but has retained ovaries, it is not possible to carry a pregnancy, but it is possible to undergo fertility treatment to retrieve eggs.

Fertility Options: IVF

Multi-Specialty Transitions Department – NORTHERN CALIFORNIA

Fertilization without medical intervention typically occurs within a fallopian tube, which connects the uterus to an ovary. In an IVF pregnancy, the union of the sperm and egg occurs in a laboratory after the eggs and sperm have been collected.

In a typical cycle, the ovary produces one egg that descends down the fallopian tube where it’s united with sperm. In IVF the goal is to stimulate multiple follicles in both ovaries, to produce multiple eggs and increase the number of potentially viable eggs.

The eggs are retrieved at the point of maturation from inside the ovaries and are fertilized in the IVF lab. Embryos are then transferred to the uterus to initiate pregnancy. Once the embryos are transferred back into the uterus, there is nothing distinguishable between embryos fertilized in the body or in an IVF laboratory.

Major steps of the IVF process:

1. Monitor the maturation of egg(s) in the ovaries. Fertility medications including hormone injections prescribed to control timing of maturation of eggs and to increase chance of collecting multiple eggs. Fertility medications and hormone injections must be carefully timed. Patients required to make multiple trips to the doctor over a period of a few weeks for evaluation and medication administration. To monitor egg development, patient undergoes ultrasound examinations of the ovaries (typically a transvaginal method of imaging the enlarging follicles containing the eggs), and measurement of blood hormone levels.

2. Collect eggs. Retrieval of the eggs is performed transvaginally (through the vagina) or laparoscopically (through the abdomen) using a hollow needle guided by an ultrasound image. This step typically happens at an outpatient procedure in the doctor’s office. A patient may need to undergo multiple rounds of steps 1 and 2 before enough viable eggs are collected for freezing.

3. If just preserving eggs then they get banked at this step.

4. If making embryos: • Obtain sperm. Eggs removed from the ovarian follicles are examined and placed with the

partner's or donor's sperm. • Eggs and sperm are joined together in the laboratory with optimal conditions for fertilization

and early embryo growth. Sperm can either be introduced to the egg in a dish or injected into the egg directly. The sperm and eggs are placed into incubators and examined to ensure that fertilization and cell division have taken place. This usually takes 2-4 days. At this point the joined egg and sperm is called an embryo and they can either be frozen for later pregnancy or implanted in the uterus.

Cost Considerations

Multi-Specialty Transitions Department – NORTHERN CALIFORNIA

Costs and Coverage

• Health plans differ in their coverage. Please contact Kaiser Permanente Member Services at 1-800-464-4000 to discuss your coverage.

• We can help you find appropriate resources.

Fertility Clinic FAQ

Multi-Specialty Transitions Department – NORTHERN CALIFORNIA

Preparing for Egg Freezing Consultation and Procedure When you explore egg freezing as a possibility for preserving your fertility, it’s a good idea to research fertility clinics and fertility doctors who provide egg freezing and storage.

The Society for Assisted Reproductive Technology (SART) maintains records of fertility outcomes on their webpage at: http://www.sart.org/clinic-pages/find-a-clinic/

(“Search by Zip Code” -> Choose Clinic -> “Success Rates and Clinic Details”)

On the SART website you can obtain information about each fertility clinic’s: • Live birth rate from frozen egg IVF, fresh egg IVF, and frozen embryos. • Live birth rate from patients vs. donors (donors may be higher because they are

often younger). • Live birth rate of patients in your age group. • Total number of patients. • Average number of egg retrieval attempts by age group. • The egg thaw survival rate.

Questions for Fertility Clinics: • Have you ever worked with transgender people to assist them with fertility? • Has your staff, particularly those who will be intimately involved with my care (e.g.,

performing ultrasounds, drawing blood) received any training on working with transgender (not just LGB) patients?

• Of the frozen eggs stored, how many people have thawed eggs at your facility? • Where are the frozen eggs stored? • What egg freezing method do you use? • How many years can the eggs can remain frozen and viable? • What are the fees for one egg freezing cycle? • What are the annual storage fees? • What are the thawing fees? • What is the average number of eggs needed? (You may have to undergo two or three cycles

and surgical egg extractions.) • How and when will the fertility clinic dispose of unused eggs? • What is the fertility clinic's back-up plan in the event of an extended power failure,

an unexpected shut down or if you stop paying your storage fees?

California Cryobank 1-866-477-3762 4292 El Camino Real Los Altos, CA 94022

California IVF Fertility Center 530-771-0177 1550 Drew Ave, Suite 100 Davis, CA 95618 916-568-2125 2288 Auburn Blvd, Ste 204 Sacramento, CA 95821

Lane Fertility Institute 415-949-1703 2100 Webster Street, Suite 332 San Francisco, CA 94115 415-949-1796 101 Rowland Way, Suite 305 Novato, CA 94945

Napa Valley Fertility Center 707.259.1955

Northern California Fertility Medical Center 1130 Conroy Lane, Suite 100 Roseville, CA 95661 1111 Exposition Blvd, #200 Sacramento, CA 95815 Tel: (916) 773-2229

Kaiser Permanente Center for Reproductive Health https://www.kpivf.com/

Pacific Fertility Center 415-834-3095 55 Francisco Street, Suite 500 San Francisco, CA 94133

Spring Fertility 415-964-5618 1 Daniel Burnham Court, Suite 110C San Francisco, CA 94109 570 Price Avenue, Suite 200 Redwood City, CA 94063

Reproductive Science Center 1-888-377-4483

Stanford (650) 498-7911

UC Davis 916-734-6900 4860 Y Street, Suite 2500 Sacramento, CA 98517

UCSF Fertility Preservation Program 415-353-9115 499 Illinois St., Sixth Floor San Francisco, CA 94158

Fertility Clinics – Northern California Resources

Multi-Specialty Transitions Department – NORTHERN CALIFORNIA

• Milk Junkies: http://www.milkjunkies.net/

• Sprouts: http://www.sproutfamily.org/

• Maia Midwifery: http://maiamidwifery.com/ • Our Family Coalition: http://www.ourfamily.org/

• American Society for Reproductive Medicine (ARSM):

• http://www.asrm.org/globalassets/asrm/asrm-content/news-and-publications/ethics-committee-